Dental clinic proves importance of care

HEALTH Lack of insurance driving patients to clinics, emergency rooms

Drew Joseph

Updated 10:45 pm, Thursday, January 31, 2013

Jabari Kelly touches the swelling around an infected wisdom tooth at the S.F. General Hospital dental clinic.
Photo: Michael Short, Special To The Chronicle

Jabari Kelly touches the swelling around an infected wisdom tooth...

Rebecca Hoffman, a professional dog walker, needed surgery after an infection around a broken molar spread into her jaw. "Something that could have been prevented wasn't," she says.
Photo: Michael Short, Special To The Chronicle

Rebecca Hoffman, a professional dog walker, needed surgery after an...

Dr. Brian Bast (left), chief of oral surgery at UCSF, and Dr. Newton Gordon, a professor, discuss services at the clinic.
Photo: Michael Short, Special To The Chronicle

Dr. Brian Bast (left), chief of oral surgery at UCSF, and Dr....

A diargam of teeth is seen on the wall in the dental clinic at SF General Hospital in San Francisco, CA Thursday January 24th, 2013.
Photo: Michael Short, Special To The Chronicle

A diargam of teeth is seen on the wall in the dental clinic at SF...

Professional dog walker and trainer Rebecca Hoffman poses for a portrait at Bernal Heights Park in San Francisco, CA Thursday January 24th, 2013. Without dental insurance and needing emergency oral surgery Rebecca was forced to visit the Dental Clinic at SF General Hospital where she will be paying out of pocket.
Photo: Michael Short, Special To The Chronicle

Professional dog walker and trainer Rebecca Hoffman poses for a...

People sit in the outpatient lobby as they wait to be seen in the dental clinic at SF General Hospital in San Francisco, CA Thursday January 24th, 2013.
Photo: Michael Short, Special To The Chronicle

The 36-year-old San Francisco man had an infected wisdom tooth, and swelling had spread into his jaw and cheek. A few more days, he was told, and the infection could have advanced below his chin, possibly restricting his breathing.

Kelly lacks dental insurance and said he had not been to a dentist in two years. His dental problems were more extreme than most, but they illustrate the importance of preventive dental care and the larger ties between dental health and overall health.

But millions of Californians have lost dental insurance in recent years as the state cut Medi-Cal dental benefits and the number of people with private insurance fell, sending more people to emergency rooms for care.

No safety net anymore

Many emergency departments don't have dentists, and what emergency physicians can do is limited. For damaged teeth, they can prescribe painkillers and antibiotics and refer patients to dentists for a tooth extraction, one procedure that is still covered by Medicaid.

"There's literally no safety net for these adults anymore," said Beth Mertz, an assistant professor at the UCSF School of Dentistry. "Once the tooth starts to go sour, unless they can find the money to pay for it out of pocket, their choice is to wait until it gets bad enough to cover it as an emergency extraction."

That is what the team at the oral and maxillofacial surgery clinic at San Francisco General was preparing to do for Kelly. The clinic has such a high demand that it has to triage patients and focus on the most pressing cases. Other patients might have to wait weeks for an appointment.

"To see the people turned away touched my heart," Kelly said. "If I wasn't as bad as I was, I would have given them my spot."

In 2009, the state cut its Denti-Cal program, eliminating nonemergency dental benefits for most adults. The move saved California more than $100 million a year, but left almost 3 million adults without coverage. Other Californians have lost private dental insurance because of unemployment or because employers stopped offering it.

That means cleanings and fillings are no longer covered, and local dentists said they are seeing more people coming to hospitals with more serious problems - a trend occurring nationwide.

There are a number of free dental clinics in California throughout the year, and some clinics offer dental care on a sliding fee scale, meaning patients pay what they can. The federal Ryan White program also covers oral health care for people with HIV and AIDS. But these programs cover only a fraction of the need.

At San Francisco General, the number of emergency visits for dental complaints grew from 365 in 2008-09 to 453 in 2009-10, according to hospital data. In 2011-12, the number of emergency visits was 651.

Patients stream in

In 2008, the hospital cut the dental clinic's hours from five days a week to three to save money. At the time, the number of annual visits was projected to drop from 6,000 to 3,500, according to Dr. Brian Bast, the chief of oral and maxillofacial surgery and an associate clinical professor at UCSF.

Instead, the clinic had more than 4,800 visits in 2008-09. Subsequent years have seen similar numbers.

"It's nice to have that service, but what we're seeing is patients, had they had access to dental care, they would have been seen by a dentist and teeth that we're removing could have been restored with a filling," Bast said.

Highland Hospital in Oakland saw similar growth in dental demands. In 2007, there were 577 dental-related visits at the emergency department there, accounting for 0.9 percent of all emergency room visits. In 2011, the number of visits was 2,718 - 3.4 percent of all visits.

More drop-in visitors

The dental clinic at Highland also saw large increases in the number of drop-in visits, a figure that includes referrals from the emergency department. In 2008, the drop-in number was less than 5,500, but it grew to more than 8,300 in 2009 and peaked at 9,500 in 2011.

For many people, dental care is not something they think about until they have a problem, said Dr. Tony Mock, the dental clinic director and chief of general dentistry at Highland.

"A lot of these people are having a hard time making ends meet, and teeth are just a last priority for them," he said.

Rebecca Hoffman, 27, who owns a dog-walking business, had looked at buying private insurance but could not afford it. The San Francisco woman said she had not been to the dentist in 10 years.

But in November, an infection around a broken molar spread into Hoffman's jaw. She eventually had to have surgery to remove the tooth and spent several days in the hospital.

"Something minor turned into something huge," she said. "Something that could have been prevented wasn't."

Risks of other health issues

Experts emphasize that quality dental care is not just for teeth's sake. People with dental health problems face higher risks of other health issues, including cardiovascular disease and diabetes. And research has shown that people with dental problems have a harder time finding jobs.